AMA Does the Right Thing--and Hopes Nobody Notices

Health reformers have finally got the American Medical Association where they want it. The AMA just signed on to a ringing statement of national purpose, and if there's no follow-through it'll be an easy target for charges of hypocrisy.

The trouble is, it's apparently up to the press to make these charges--and the press doesn't seem to be paying attention.

When the AMA's House of Delegates met in Chicago last week, reporters had some lively stories to cover. There was a resolution endorsing legislation to require Catholic hospitals to offer "a full range of reproductive services," including birth control. After Cardinal George testified before the delegates, that resolution was watered down. There was a resolution calling for a moratorium on executions. It was watered down too.

Both of these issues drew a lot of ink. Meanwhile, flying below the radar was a resolution that the delegates "strongly affirm" the proposition "All Americans must have health insurance." This resolution wasn't reported, it wasn't debated, and many of the delegates probably never knew they'd voted for it. Since it proposes no means of getting from the current mess to universal health insurance, its utilitarian value can be questioned. It does give the AMA an opportunity to pat itself on the back, but the AMA isn't taking it.

"It was one of the most significant things to come out of the House of Delegates," says Raymond Scalettar, a New York City doctor and former chairman of the AMA board of trustees. "Everybody should be proud of the AMA for being so forthright."

Then why hasn't the AMA called attention to what it did?

"That's why we have people like you," he says.

To review the history of the AMA is to appreciate that something of magnitude did happen. "Even if it's empty rhetoric it's an amazing thing," says a doctor friend who's never joined the AMA because she finds its politics so offensive. An author of the resolution, Dr. Ann Marie Dunlap, hand delivered me a copy of The Serpent on the Staff, the 1994 dissection of AMA politics by Sun-Times reporters Howard Wolinsky and Tom Brune, and directed me to the second chapter. There the authors describe six battles this century between Washington and the AMA over national health care insurance. The AMA lost on medicare but won every other battle.

But the last several years have transformed health care and the health care establishment in America. The bedrock-American and usually highly profitable private practice has given way to for-profit HMOs, whose doctors--at least those doctors without a piece of the ownership--feel like hired hands. Doctors have splintered into specialties, each with its own professional organization. And a decade of affluence has made the vast number of Americans with no health insurance whatsoever seem less like a Malthusian inevitability than a national disgrace. According to statistics presented last week to the AMA, 44 million Americans--16.3 percent of the population--are uninsured. In Illinois the number is 15 percent, in Chicago, 17.3 percent. Worst off are southern suburbs in Ann Marie Dunlap's backyard; in Ford Heights 30.7 percent of residents are uninsured. And these figures were compiled in 1997 and 1998--the best of economic times.

Despite no consensus over how to achieve it, the notion of universal health coverage has become irresistible, with Chicago and Illinois central to the movement. The late Cardinal Bernardin pleaded for it in a 1995 pastoral letter. And though the Sun-Times reported that Cardinal George's testimony before the House of Delegates last week was "unprecedented," in fact Bernardin had appeared before it in December 1995, not long after learning he had pancreatic cancer.

In death he's identified with the principle of universal coverage. The so-called Bernardin Amendment, which would add health care to the Illinois constitution as a fundamental right, has gone nowhere in the General Assembly, but in an advisory referendum in 1998 it was supported by 83 percent of Cook County voters. The following April, 23 more jurisdictions in Illinois approved the same amendment. The reaction of the medical establishment can be seen in a February 1999 memo from the chairman of the Illinois State Medical Society to ISMS officers and trustees. It warned that implementation of the amendment could easily lead to "a state government run single payer system...in clear conflict" with ISMS policy.

Last spring Whitney Addington, former chairman of the Cook County Board of Health, became president of the nation's second largest society of doctors, the American College of Physicians-American Society of Internal Medicine. He declared that he wanted his presidency judged on the basis of the progress he made toward achieving universal coverage, and he soon convened a working group of top doctors from the ACP-ASIM, the AMA, and five other professional organizations. This group produced the statement "All Americans Must Have Health Insurance," which 49 medical organizations, including the AMA, subsequently signed.

The statement is a group effort and reads like it. It proposes an "ideal," and says next to nothing about how to achieve it. "Expanding the individual's ability to choose among several health insurance options is crucial," says the statement. "We support pluralism of health care delivery systems and financing mechanisms in achieving coverage for and access to health care services." In the name of universal health coverage, doctors who think the only way to achieve it is through a single-payer system such as Canada's could bite their lip and sign on. So could doctors to whom a single-payer system is bolshevism. The fears of the ISMS and its like had been dealt with.

What distinguishes the statement is its one specific call to action. "There currently exists an important 'window of opportunity' to influence public policy with the upcoming 2000 elections," it declares. "We challenge the 106th Congress and declared 2000 presidential candidates to make the critical issues of health insurance coverage and access a top priority." While the signatories might support varying approaches to the same end, all "consider it imperative to push the issue onto the national agenda, increase public awareness, and set off a public debate of the issues involved."

To Ann Marie Dunlap and other doctors, the AMA is the one medical organization with the political muscle and sophistication to actually wade in and influence electoral politics. Though the AMA's leadership was already on board, at least formally, Dunlap--who is secretary of the south Cook Branch of the Chicago Medical Society--reasoned that it was crucial to get the statement ratified by the House of Delegates. These delegates represent state medical societies and specialist organizations, and the state societies, she explained to me, have their own lobbyists and political action committees. If they chose to wage political battle they could turn the 2000 elections on their ear.

So Dunlap wrote a resolution that called on the House of Delegates to affirm "All Americans Must Have Health Insurance" and go home and have their state societies "strongly affirm" it too. Not being a delegate herself, she passed her resolution to Dr. Earl Fredrick Jr. and asked him to introduce it in Chicago.

He promptly rewrote her draft. His version still asked the delegates to endorse "All Americans Must Have Health Insurance," but he decided against showing them the entire text of that document. Instead he quoted highlights. Out went the politics--every allusion to a 2000 battle plan. "I felt it had a better chance of passing the AMA," Fredrick told me. Delegates familiar with the joint statement would already know about the "window of opportunity." Other delegates didn't need to know. "I didn't have to state it in the whereases and have people jumping up on the floor" in protest.

James Webster, who teaches medicine at Northwestern University and chairs the Illinois Ad Hoc Committee to Defend Health Care--similar ad hoc committees have sprung up all over the country--testified in favor of the resolution. Citing some recent studies, he said universal coverage "is not only good medicine but it's good economics."

Webster told me later, "I think it's a nice start. I don't think the AMA will do anything with it. It's an apple-pie-and-motherhood kind of thing, so it was pretty easy for a lot of people to sign on. I'm not too optimistic the AMA is going to carry this down the field for six points--"

He paused, and I encouraged him to keep going.

"--running roughshod over the entire secondary of the insurance industry."

He also said, "People are raping the system right and left, the for-profit insurance companies. I went down to the AMA to give testimony on this, and I had to sit through four and a half hours of the most disgraceful greed, most of which had to do with insufficient reimbursements. We had neurosurgeons and gastroenterologists, and you'd have thought they were down to their last nickel and needed a tag day.

"My own existentialist opinion is that nothing will change things but the next recession or depression. Then you'll have 90 or 100 million people uninsured, and you'll have a major issue."

Fredrick and Webster didn't get to testify to the full house. They merely appeared before one of several AMA "reference committees" that met as the delegates gathered in Chicago and decided what to do with the hundreds of resolutions the delegates were bringing with them. Dunlap thinks it significant that the reference committee didn't get around to Fredrick's resolution until the very end of the day--when any reporters who might have been present would surely have left. That's why Webster had to sit around for hours.

Nobody testified against the resolution, which allowed the reference committee to put it on the vast consent calendar of resolutions slated to pass en masse without discussion. Dunlap reads the committee's behavior as an exercise in passive aggression; the resolution would be ratified in such obscurity that no one would realize it existed.

"When it's on the consent calendar it's lost in space," says Howard Wolinsky. (He's still at the Sun-Times but no longer covers the AMA.)

The complete lack of coverage is evidence to Dunlap that the AMA's tactics worked.

I spoke up for the press corps. I said the breaking news value of the resolution was hard to see. It wasn't much of a call to action, and the AMA leadership had already signed on. (An AMA spokesman points out to me that the resolution could already be found on the AMA Web site if you knew what you were looking for and that the AMA had begun touting universal coverage as a political issue last December. He said nothing had happened last week to make a fuss about.)

"They are trying to downplay this terribly," Dunlap insists. "They don't want it to be a major issue in the election. The title of Dr. Fredrick's resolution was 'All Americans Must Have Health Insurance: A Call for High Priority Commitment.' With the kinds of things he deleted, he still thinks they must give it high priority. This is not minor stuff. What the AMA does not want is [political] candidates to be made or broken on the basis of whether we have complete [medical] coverage."

Dunlap finds it suspicious that the AMA leadership, the agent of change, didn't itself bring the statement to the House of Delegates. That task was left to backbench troublemakers.

"The whole purpose of this statement was to make it part of the election debate. Is the AMA doing this? No. Are they going to? No. Except that they are on record as accepting this as a high priority."

And who, I asked, will hold the AMA's feet to the fire?

"The press," she said.

Uh-oh.

Looking back over his 15 years covering the AMA, Wolinsky tells me, "Everything makes them queasy." It's one step forward, another back. In 1989, says his book, AMA leaders "announced with great fanfare that the delegates would be voting on a patients' Bill of Rights" at the December meeting. But the delegates refused to ratify it. What they passed instead boldly asserted patients' right to "the availability of care."

When the AMA is proud of something its House of Delegates does ratify, that something is usually hailed at a press conference. This year the health coverage resolution didn't come up. Bruce Japsen, who covered the meeting for the Tribune and was vaguely aware of the resolution, said it was like the issue didn't exist. "There was buzzing about the cardinal, buzzing about patients' rights and managed care and things that affect doctors' pocketbooks, frankly. It didn't seem there was a buzz about this."

I told Dunlap that the universal-coverage forces have some serious work to do before they can rope in the press as an ally.

"If what you're telling me is [reporters] don't believe this is newsworthy, it's kind of scary. It's kind of scary to those of us who belong to this organization and read this stuff and believe [AMA leaders] mean it. If they don't mean it, then what is organized medicine about? This is the first time 49 organizations have joined with the AMA on anything."

Dr. Quentin Young of the American Public Health Association is another who testified before the reference committee on the universal health coverage resolution. "It's of some importance that the AMA is being pressed to join the rest of society in this matter," he told me later. But he's not sure how much. "The AMA has been dancing around universal coverage for the longest time. Finally they got into the lip-service business."

411 Is a Joke

The Sun-Times can't be praised highly enough for its brilliant front-page exposé last Sunday, "4-1-1 Mistakes Cost Callers Millions." Reporter Shu Shin Luh transcended ordinary muckraking journalism to perform the crucial community service of making every reader recognize that he or she is not alone. Information services are one of the great scandals of our time, as is just about everything else to do with modern telephone communications, and the moment I saw the headline I realized how much I'd been aching to have someone say so. Luh alertly pointed out that as infuriating as it is to pay 95 cents and get a completely wrong number, it's just as bad to get one that's almost right--as when, to draw from my own experience, you ask information for the number of a newspaper in Manhattan and wind up with an advertising office it maintains on Long Island. Luh provided readers with many helpful rules for fighting back--and another I'd add is this: if you want to call some major company and the number you're given doesn't end in double zero or some striking pattern, it's the wrong number and you should insist that the operator check again.

That is, if the operator comes back on the line.

"Customers can get refunds," wrote Luh, "but few bother." The bother is extraordinary. If 411 gives you the wrong long-distance number, as you don't discover until you dial it, you have now paid for two useless calls and must contact two separate companies to get your money back. Unless self-respect isn't an issue with you, cancel your appointments, call Ameritech, or whoever gave you the wrong number, and raise hell. Then call AT&T or MCI or whoever your long-distance carrier is and ask it for your money back too. Be a nuisance. Be surly. Put the fear of God in the operators at the other end of the line, who of course aren't the ones responsible for your problem.

Luh did an admirable job of not merely identifying the problem but explaining why it exists. The reason, not surprisingly, has a lot to do with sweatshop conditions--a handful of poorly paid operators forced to meet brutal quotas while relying on second-rate technology. From time to time I'm able to talk to an operator long enough to commiserate. When I tell operators that for the benefit of the tape recorders that monitor every breath they take I'd like to say they work for vicious assholes, they seem to appreciate it. But too much chitchat and they fall far behind on their quotas.

Much has been written about the free-flowing, inchoate hate that suffuses modern society. A newspaper that can put its finger on this hatred and explain why it's justified needn't fear for its future. In the same edition of the Sun-Times I read that Jim Carrey is considering a thriller for his next movie--"Joel Schumacher's 'The Phone Booth,' set entirely in the title location." I imagine the killers will be closing in while Carrey dials frantically for help and can't find a human voice. The last words he ever hears will be, "You may choose from the following options..."

News Bites

Full disclosure's a nice thing to provide, but it's not a blanket exemption from all sins. Someone called to point out last Sunday's column by Sun-Times financial columnist Terry Savage. It was a long, chummy interview with Ralph Wanger, manager of the Acorn Fund, and at the end of it her paper dutifully came clean: "Terry Savage is a registered investment adviser for stocks and commodities and is a director of McDonald's Corp. and Pennzoil-Quaker State Co. She also is a long-time investor in several Acorn funds."

She's more than just a journalist. But being more can also mean being less.

The gifts of fairness, of indomitability, and of letting more interesting people speak have paid off big-time for Bruce DuMont. Next Tuesday he celebrates 20 years on radio hosting a political talk show, first Inside Politics and now Beyond the Beltway. He's gone from a thousand-watt station in Evanston in 1973 to national syndication.

Art accompanying story in printed newspaper (not available in this archive): illustration/Peter Shaulis.